Unit IV. Prevention
Education
Preventing Transmission of HIV/AIDS thru Sexual Contact
In the United States, complacency about the need for HIV prevention may be among the strongest barriers communities face as they plan to meet the next century's prevention needs. The great success that many people, but not all, have had with new highly active antiretroviral therapies (HAART, also known as drug "cocktails") and the resulting decline in the number of newly reported AIDS cases and deaths are indeed good news. The underlying reality, however, is that the HIV epidemic in our country is far from over. This is true not only for the nation, but for the continuing number of HIV-infected individuals who now must face years - perhaps a lifetime - of multiple daily medications, possible unpleasant or severe side effects, and great expense associated with the medicines needed to suppress HIV and prevent opportunistic infections.
The success of HAART is good news for the people living longer, better lives because of it, but the availability of treatment may lull people into believing that preventing HIV infection is no longer important. This complacency about the need for prevention adds a new dimension of complexity for both program planners and individuals at risk.
While the number of AIDS cases is declining, the number of people living with HIV infection is growing. This increased prevalence of HIV in the population means that even more prevention efforts are needed, not fewer. For individuals at risk, increased prevalence means that each risk behavior carries an increased risk for infection. This makes the danger of relaxing preventive behaviors greater than ever.
Past prevention efforts have resulted in behavior change for many individuals and have helped slow the epidemic overall. However, many studies find that high-risk behaviors, especially unprotected sex, are continuing at far too high a rate. This is true even for some people who have been counseled and tested for HIV, including those found to be infected.
The long-term effectiveness of HAART is unknown. Further, HIV may develop resistance to these drugs. The powerful treatments are complicated and involve taking large numbers of pills. Even the most motivated patients may forget to take all their medications or skip doses. Some patients have been known to take "drug holidays," completely stopping their medications for a number of days or weeks. These drug treatments are less effective when treatment schedules are not followed. Diversions from the prescribed treatment regimen increase the possibility of drug resistance developing, which would greatly narrow future treatment options for those infected with a drug-resistant strain of HIV. And, if the development of drug-resistance is coupled with a relaxation in preventive behaviors, resistant strains could be transmitted to others and spread widely.
Research among gay and bisexual men suggests that some individuals are less concerned about becoming infected than in the past and may be inclined to take more risks. This may be equally true in other groups at risk who might believe they no longer need to use condoms because protease inhibitors are so effective in treating HIV disease. The truth is, despite medical advances, HIV remains a serious and usually fatal disease that requires complex, costly, and difficult treatment regimens. These treatments don't work for everyone. Sometimes when they do work, they have unpleasant or intolerable side effects. Some people can't take them because the interaction with their other drugs causes serious problems. Still others find it extremely difficult to maintain the drug treatment schedules. As we continue working to develop better treatment options, we must not lose sight of the fact that preventing HIV infection in the first place precludes the need for people to follow these difficult regimens.
Behavior Modification
- Abstinence - The only 100% "Safe Sex" Practice
- Mutual monogamy with an uninfected partner - "Safer Sex"
- Latex condoms - "Safer Sex"
- Avoiding injection drugs
- Comprehensive HIV Prevention Messages for Young People
HIV-related illness and death now have the greatest impact on young people. AIDS is a leading cause of death among Americans 25 to 44 years-old. In this same age group, AIDS now accounts on average for 1 in every 3 deaths among African-American men and 1 in 5 deaths in African-American women. Between 1990 and 1995, AIDS incidence among people 13 to 25 years old rose nearly 20%. While AIDS incidence among both young gay and bisexual men and young injecting drug users was relatively constant during this time period, AIDS incidence among young heterosexual men and women rose more than 130%.
A study by the National Cancer Institute confirms existing data which reveal that as each generation comes of age, there is a substantial increase in the rate of infection as individuals enter their late teens and early twenties, with infection rates peaking in the mid-to-late twenties. Sustained, targeted prevention for each group entering young adulthood is what will keep these waves from developing. As the lead federal agency for HIV prevention, CDC is responsible for implementing public education programs to help stop the spread of HIV and other sexually transmitted diseases (STDs).
A Balance of Prevention Messages is Needed--Including Abstinence and Condom Use
Behavioral science has shown that a balance of prevention messages is important for young people. Total abstinence from sexual activity is the only sure way to prevent sexual transmission of HIV infection. Despite all efforts, some young people may still engage in sexual intercourse that puts them at risk for HIV and other STDs. For these individuals, the correct and consistent use of latex condoms has been shown to be highly effective in preventing the transmission of HIV and other STDs. Data clearly show that many young people are sexually active and that they are placing themselves and their partners at risk for infection with HIV and other STDs. These young people must be provided the skills and support they need to protect themselves.
Effectiveness of Condoms
Condoms are classified as medical devices and are regulated by the Food and Drug Administration (FDA). During the manufacturing process condoms are double-dipped in latex. Condom manufacturers in the United States test each latex condom electronically for defects, including holes, before it is packaged. The proper and consistent use of latex or polyurethane (a type of plastic) condoms when engaging in sexual intercourse--vaginal, anal, or oral--can greatly reduce a person's risk of acquiring or transmitting sexually transmitted diseases, including HIV infection.
There are many different types and brands of condoms available--however, only latex or polyurethane condoms provide a highly effective mechanical barrier to HIV. In laboratories, viruses occasionally have been shown to pass through natural membrane ("skin" or lambskin) condoms, which may contain natural pores and are therefore not recommended for disease prevention (they are documented to be effective for contraception). Women may wish to consider using the female condom when a male condom cannot be used.
For condoms to provide maximum protection, they must be used consistently (every time) and correctly. Several studies of correct and consistent condom use clearly show that latex condom breakage rates in this country are less than 2 percent. Even when condoms do break, one study showed that more than half of such breaks occurred prior to ejaculation.
When condoms are used reliably, they have been shown to prevent pregnancy up to 98 percent of the time among couples using them as their only method of contraception. Similarly, numerous studies among sexually active people have demonstrated that a properly used latex condom provides a high degree of protection against a variety of sexually transmitted diseases, including HIV infection.
Condoms and Their Use in Preventing HIV Infection and Other STDs
With nearly 1 million Americans infected with HIV, most of them through sexual transmission, and an estimated 15 million cases of other sexually transmitted diseases (STDs) occurring each year in the United States, effective strategies for preventing these diseases are critical. Refraining from having sexual intercourse with an infected partner is the best way to prevent transmission of HIV and other STDs. But for those who have sexual intercourse, latex condoms are highly effective when used consistently and correctly.
Laboratory studies show that latex condoms are effective barriers to HIV and other STDs. In addition, several studies provide compelling evidence that latex condoms are highly effective in protecting against HIV infection when used for every act of intercourse. This protection is most evident from studies of couples in which one member is infected with HIV and the other is not, i.e., "discordant couples" .
Several studies clearly show that condom breakage rates in this country are less than 2%. Most of the breakage and slippage likely is due to incorrect use rather than poor condom quality. Using oil-based lubricants can weaken latex, causing the condom to break. In addition, condoms can be weakened by exposure to heat or sunlight or by age, or teeth or fingernails can tear them. Studies also indicate that condoms slip off the penis in about 1-5% of acts of vaginal intercourse and slip down (but not off) about 3-13% of the time.
Condoms must be used consistently and correctly to provide maximum protection
There are several types of condoms. Nearly all types offer protection against HIV and other STDs.
Latex condoms for men. Latex condoms are made of a particular kind of rubber. Laboratory studies show that intact latex condoms provide a highly effective barrier to sperm and micro-organisms, including HIV and the much smaller hepatitis B virus. Their effectiveness has been proven over many years.
Synthetic condoms. For people who are allergic to latex, several new types of materials are being used to make condoms. One new type is polyurethane, a soft plastic. Another new type is Tactylon TM *, a synthetic latex. Lab tests have shown that both these materials provide an effective barrier against sperm, bacteria, and viruses such as HIV.
Polyurethane condoms for women. The female condom (Reality TM* ) fits inside the vagina and covers some of the area outside of the vagina. It also is made of polyurethane. When a male condom cannot be used, couples should consider using a female condom.
Unlike latex condoms, synthetic condoms such as male and female polyurethane condoms can be used with either water-based or oil-based lubricants.
Although not as thoroughly tested as latex condoms, synthetic condoms likely provide similar protection.
Lambskin condoms. These condoms are made from animal membranes that contain tiny holes. While they can prevent pregnancy, they should not be used for STD or HIV prevention because viruses may be able to pass through these holes.
Novelty condoms. Novelty (play) condoms are for sexual amusement only. The FDA does not allow them to be labeled as condoms, and they should never be used for STD/HIV or pregnancy prevention.
Spermicides. Although studies indicate that nonoxynol-9, a spermicide, kills HIV in laboratory testing, it is not clear whether spermicides used alone or with condoms during intercourse provide protection against HIV. Therefore, latex condoms with or without spermicides should be used to prevent sexual transmission of HIV.
